恶性肿瘤病历主要诊断选择思路分析  

Analysis of Main Diagnostic Options for Malignant Tumor Records

作　　者：袁东方 张刚刚 YUAN Dong-fang;ZHANG Gang-gang(Department of Medical Records Statistics,Xiasha Hospital,Hangzhou 310018,Zhejiang,China)

机构地区：[1]杭州市下沙医院病案统计科,浙江杭州310018

出　　处：《医学信息》2018年第7期28-29,共2页Journal of Medical Information

摘　　要：通过对恶性肿瘤患者病历ICD-10编码分析,探讨如何选择正确的主要诊断。影响病案主要诊断选择的因素有:临床医师对主要诊断选择不够重视;编码员对ICD-10编码知识不够熟练。因此编码员在掌握疾病分类编码的基础上,要仔细阅读病案,根据病因、病理、解剖部位、住院目的等填写正确的主要诊断,为之编码,有效的为临床教学、科研等提供依据。By analyzing the ICD-10 code of patients with malignant tumor,this paper discusses how to select the correct main diagnosis.The factors influencing the main diagnostic choices of medical records are:the clinicians do not pay enough attention to the main diagnostic choices and the encoder is not proficient in ICD-10 coding knowledge.Therefore,on the basis of mastering the classification and coding of diseases,the encoder should read the medical records carefully,fill in the correct main diagnosis according to the etiology,pathology,anatomical location,and the purpose of hospitalization,and code for them,effectively provide the basis for clinical teaching and scientific research.

关 键 词：恶性肿瘤 主要诊断 ICD-10 

分 类 号：R195.4[医药卫生—卫生统计学] R730.4[医药卫生—卫生事业管理]